Study Suggests No Advantage in Collaborative Care vs. Usual Care for Veterans with PTSD
BACKGROUND:
Although VA now requires mandatory PTSD screening in primary care clinics, Veterans with PTSD who are treated in these settings may have fewer visits for PTSD, or be less likely to obtain medication treatment relative to Veterans who are treated in specialty mental healthcare. There have been no published randomized controlled trials (RCTs) of primary care-based treatment specifically for patients with PTSD. This RCT compared a collaborative approach — the Three Component Model (3CM) — with usual care for treating PTSD in primary care. Investigators recruited 195 Veterans (40% served in Iraq or Afghanistan; 42% in Vietnam) from five primary care clinics at four VA healthcare facilities from 3/08 through 4/10. Participants were randomly assigned to receive usual care alone or usual care in addition to 3CM, which also provided telephone care management. The primary outcome measured was PTSD symptom severity. Secondary outcomes included depression, functioning, perceived quality of care, healthcare use, and costs.
FINDINGS:
- Over a 6-month period, primary care patients with PTSD in both 3CM and usual care groups showed small but clinically insignificant improvement in PTSD, depression, and functioning. No additional benefit was found for Veterans assigned to the 3CM treatment compared to those receiving usual care, despite the fact that 3CM patients were more likely to receive an antidepressant and had more mental health visits.
- Among Veterans who provided a numeric rating for PTSD care, half rated it as excellent or very good; however, 3CM was associated with lower perceived quality of PTSD care. Almost two-thirds of Veterans rated their overall care as excellent or very good, and the groups did not differ.
- Costs were similar for both groups, except that Veterans assigned to 3CM had higher outpatient pharmacy costs.
IMPLICATIONS:
- The authors state that it would be premature to conclude from these findings that 3CM is not effective for treating PTSD in primary care settings. A large, uncontrolled study in the Army suggested a larger benefit of 3CM among soldiers treated at an earlier stage. The severity and comorbidity in VA patients with PTSD may underlie the smaller effects of evidence-based PTSD treatment in the VA population. However, this study suggests the need for careful examination of how collaborative care models for PTSD are implemented — and for additional support to encourage primary care providers to manage PTSD.
LIMITATIONS:
- Findings may not generalize to settings where access to mental healthcare is lower.
- Outcomes may have differed if the study had been longer, e.g., 12 months as in the IMPACT study and other studies of collaborative care for depression.
AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (IAC 06-073). Drs. Schnurr, Friedman, and Shiner, and Mss. Forshay and Thurston are part of VA's National Center for PTSD, White River Junction, VT. Dr. Smith was part of HSR&D's Health Economics Resource Center, Palo Alto, CA.
Schnurr P, Friedman M, Oxman T, Dietrich A, Smith M, Shiner B, Forshay E, Gui J, and Thurston V. RESPECT-PTSD: Re-Engineering Systems for the Primary Care Treatment of PTSD, A Randomized Controlled Trial. Journal of General Internal Medicine August 3, 2012;Epub ahead of print.
